BACKGROUND & AIMS: Patient navigation interventions can improve health outcomes in underserved, low-income, and racial and ethnic minority groups, who often experience health disparities. We examined the effectiveness of patient navigation to improve linkage to hepatitis C virus (HCV) treatment receipt in a socioeconomically disadvantaged, racially diverse patient population. METHODS: We performed a pre-post analysis evaluating the effectiveness of a patient navigation program among baby boomers who tested positive for HCV in a safety-net health system. The usual care group (June 2013 to May 2015) and patient navigation group (January 2016 to December 2017) were balanced using a stabilized inverse probability of treatment weighting approach. We used logistic regression analyses to evaluate associations between patient navigation and linkage to care for HCV treatment evaluation, treatment initiation, and sustained virologic response. RESULTS: Among 1353 patients (62% black, 61% uninsured, 16% homeless), 769 were in the usual care group, and 584 were in the patient navigation group. The patient navigation group had significantly higher odds of linkage to care (odds ratio [OR], 3.7; 95% confidence interval [CI], 2.9-4.8) and treatment initiation (OR, 3.2; 95% CI, 2.3-4.2) within 6 months. The patient navigation group continued to have increased linkage to care (OR, 3.4; 95% CI, 2.7-4.3) and treatment initiation (OR 2.3; 95% CI, 1.7-3.0) at 12 months. However, there was no significant difference in sustained virologic response between the groups (86.9% vs 86.1%; P [ .78). CONCLUSIONS: Patient navigation was associated with significantly increased linkage to care and treatment initiation among patients with HCV infection. Patient navigation programs can be used to promote HCV elimination among traditionally difficult-to-reach patient populations.

Abstract Background In 2015, a Best Practice Alert (BPA) was implemented into our electronic health record that prompts ordering of Hepatitis C Virus (HCV) antibody (Ab) screens for unscreened patients born between 1945-1965 (baby boomers: BB). The BPA begins the first step of the three-step care cascade, after which follow-up is needed for RNA testing if Ab-positive and HCV clinic visit if RNA-positive (figure 1). Prior studies found a 3.5-fold increase in HCV Ab screening after BPA implementation. We sought to understand the BPA’s role in cascade navigation during the COVID-19 pandemic. Initial BPA is triggered, which leads to subsequent steps including HCV antibody testing, HCV RNA testing, and ending with a clinic visit for treatment initiation. Methods This retrospective study included BB receiving their first BPA between 7/1/18-12/31/19 (pre-pandemic: PP) and 1/1/20-7/1/21, (intra-pandemic: IP), excluding patients with a death date ≤ 180 days after their BPA. Patients were followed for 180 days for each step and were marked unsuccessful if it was not completed. Successful navigation (SN) was defined as completing all steps or testing negative at any step. Hazard ratios for completion of each step were calculated via Cox Proportional Model. Clinical and demographic predictors of SN were examined via multivariable logistic regression in each cohort. Results Overall, 14,236 unscreened BB had a BPA (8,090 PP, 6,146 IP) fire during the study periods. The cohorts were similar, except for an increase in share with county financial assistance and those cared for by advanced practice providers in the IP cohort (table 1). An increase in HCV Ab screening (aHR 1.31 [95% CI: 1.25, 1.38]) and decreases in HCV RNA testing (aHR 0.79 [0.65, 0.96]) and clinic visits (aHR 0.43 [0.28, 0.66]) were seen in the IP cohort (figures 2A, B, and C). Hispanic patients had increased odds (aOR: 1.25 [1.02, 1.54]) of SN in the IP cohort (figures 3A and B). Compared to family medicine, those cared for in geriatric clinics had lower odds (aOR 0.75 [0.62, 0.91]) of SN in the IP cohort. Lower odds were also seen for those with Charlson Index ≥ 2 (aOR 0.85 [0.74, 0.98]) compared to 0.Table 1.Cohort Demographics.Baseline demographic, comorbidity, and provider factors for the pre-pandemic and intra-pandemic cohorts. Figure 2. Survival-Time Analysis of the HCV Care Cascade. Kaplan-Meier curves with 95% confidence intervals depicting time to completion by day after step initiation in each cohort. Data for the HCV antibody screening (A), HCV RNA testing (B), and liver clinic visit (C) steps are each shown separately. Log-rank test p-values are shown. Figure 3. Logistic Regression Forest Plots Forest plots showing the adjusted odds ratios and 95% confidence intervals for successful cascade navigation in the pre-pandemic (A) and intra-pandemic (B) cohorts. Odds ratio less than 1 indicates lower odds of successful navigation during that period. Odds ratio greater than 1 indicates higher odds of successful navigation. Conclusion The BPA increased the durability of HCV Ab screening rates during the pandemic compared to other steps in the cascade. Disparities in completing all steps of the cascade persisted and likely worsened in some groups during the pandemic. Overall, electronic reminders lessen impacts of disruptions in healthcare services. Disclosures Mamta K. Jain, MD, MPH, Gilead Sciences: Grant/Research Support|Laurent: Grant/Research Support

INTRODUCTION: Hepatitis C virus (HCV) treatment can significantly reduce the risk of liver-related mortality; however, many patients remain unaware of their infection in clinical practice. The aim of this study is to compare the effectiveness of inreach, with and without mailed outreach, to increase HCV screening and follow-up in a large, difficult-to-reach patient population. METHODS: We conducted a pragmatic randomized clinical trial from August 2018 to May 2019 in a large safety-net health system. Patients born between 1945 and 1965 were randomly assigned (1:1) to inreach with an electronic health record reminder to providers (n = 6,195) or inreach plus mailed HCV screening outreach (n = 6,191) to complete HCV antibody screening. Outreach also included processes to promote HCV RNA testing among those with a positive HCV antibody and linkage to care among those with positive HCV RNA. The primary outcome was completion of HCV antibody testing within 3 months of randomization (ClinicalTrials.gov NCT03706742). RESULTS: We included 12,386 eligible patients (median age 60 years; 46.5% Hispanic, 33.0% Black, and 16.0% White). In intent-to-treat analyses, HCV screening completion was significantly higher among inreach-plus-outreach patients than inreach-alone patients at 3 months (14.6% vs 7.4%, P < 0.001) and 6 months (17.4% vs 9.8%, P < 0.001) after randomization. Among those who completed HCV screening within 6 months, a higher proportion of inreach-plus-outreach patients with positive antibody results completed RNA testing within 3 months than inreach-alone patients (81.1% vs 57.1%, respectively, P = 0.02); however, linkage to care within 3 months of HCV infection confirmation did not significantly differ between the 2 groups (48.1% vs 75.0%, respectively, P = 0.24). DISCUSSION: Among difficult-to-reach patients, a combination of inreach and mailed outreach significantly increased HCV screening compared with inreach alone. However, HCV screening completion in both arms remained low, highlighting a need for more intensive interventions.

Abstract Background In 2016, we implemented a hepatitis C (HCV) screening program for baby boomers (BB) born between 1945 and 1965) using a best practice alert (BPA) in the electronic medical record and patient navigation (PN) in our safety-net hospital system. We now examine barriers to HCV treatment among those who received PN for linkage to care (LTC). Methods The BPA prompts providers to order a HCV antibody (Ab) for any unscreened BB who has an outpatient appointment. Those with HCV Ab+ with a confirmatory RNA receive telephone navigation, using a pre-defined script, if LTC did not occur within 2 months of RNA testing. After LTC, a person was considered as untreated if HCV treatment had not occurred within 1 year of initial visit. Insured patients received treatment through prior authorizations and uninsured through pharmaceutical patient assistance programs. We examined demographics, homelessness, insurance, fibrosis score, substance use, and psychiatric illness, as potential predictors to treatment initiation using univariate and multivariate logistic regression analysis. Results Among the 16,363 BBs screened from March 1, 2016 to December 31, 2017, 1,445 (8.8%) were HCV Ab+ and 1,038 (72%) had HCV RNA completed. Among the 724 (5%) with confirmed HCV infection, 139 (19%) received LTC without navigation, 299 (41%) received navigation, and 286 (40%) could not be contacted after three attempts. Among those who received navigation, 225 (75%) completed a follow-up visit of which 81 (36%) did not start treatment, 34 (15%) are awaiting treatment initiation, and 110 (49%) started treatment. Gender, race/ethnicity, psychiatric illness, and homelessness were not predictive of starting HCV treatment. In univariate analysis, current substance use vs. none/past use (OR 0.52 (0.29, 0.93)) was associated lower likelihood of starting treatment and advanced fibrosis (OR 2.25 (1.20, 4.21)) was associated with higher likelihood of starting treatment). Compared with uninsured patients, Medicaid patients were less likely to start treatment (AOR 0.15 (0.67, 0.34)) in a multivariate analysis. Conclusion Insurance status was independent predictor of starting treatment among patients at our safety-net hospital. Medicaid remains a barrier to HCV treatment access in safety-net systems. Disclosures A. Singal, Gilead Sciences: Grant Investigator, Research support. M. K. Jain, Gilead Sciences: Grant Investigator, Grant recipient and Research support. Janssen: Investigator, Research support. GSK/ViiV: Investigator, Consulting fee and Research support. Merck: Investigator, Research support